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home - Biliary - Gallstone Disease - Acute Cholecystitis Written by Dr Sebastian Zeki
Knowledge


Knows the physiology and biochemistry of bile and the pathogenesis
of gallstones

Is familiar with the normal anatomy and the anatomical variations of
the biliary tree

Recognises the symptoms and signs of the potential complications of
galllstone disease including biliary colic acute cholecystitis jaundice
due to calculous bile duct obstruction cholangitis and carcinoma

Knows the various techniques of diagnostic imaging including
ultrasound CT MRI ERCP EUS radionuclide techniques

Knows the various treatment options the indications for operative and
non-operative management and the risks of each

Knows the current national guidelines for use of ERCP and the risks
of the technique

Knows the ways in which gallbladder polyps are diagnosed and
managed

Knows that gallbladder and sphincter of Oddi dysfunction (SOD) may
account for otherwise unexplained abdominal pain

Recognises different types of SOD how they may present and how
they are investigated

Skills
Can select the most appropriate diagnostic and therapeutic
techniques for each clinical situation

Recognises possibility of diagnostic uncertainty in biliary dysmotility
and shows thoughtful judgement in each individual situation

Behaviours
Makes appropriate assessment stratifies urgency and plans
management of patients who have complications of gallstones

Acute Cholecystitis

False -ve results rare- may be due to incomplete cystic duct obstruction.USS— Se and Sp = 88% and 80% respec.MRCP—100% sensitivity for cystic duct stones Not as good as USS for wall oedema/ pericholecystic fluidCT scan — A)Gallbladder wall oedema B) Pericholecystic stranding and fluidC) High-attenuation bile.CT can be usefulto look for complicationsHIDA scan — Clinical presentationPatient have a positive Murphy sign. DiagnosisBloods often show a leucocytosis with normal LFTs.If doubt re USS findings, then for cholescintigraphy. Taken up by hepatocytes Excreted in bile Non-visualisation= Positive test due to oedema/ stone obstructing cystic duct Cholescintigraphy Sen 97% and Spec 90% False positives Obstruction in duct in absence of acute cholecystitis (eg stone/ tumour) -Severe liver disease, which may lead to abnormal uptake and excretion of the tracer. Already maximally filled gallbladder in prolonged starvation eg TPN Sphincterotomy, therefore bile falls out without filling gallbladder -Hyperbilirubinemia, which may be associated with impaired hepatic clearance of iminodiacetic acid compounds Inc bili Acute cholecystitis Analgesia-Opioids /ketorolacAntibiotics — -46 % have +ve bile cultures. (E.coli/Enterococcus/Klebsiella) Prognosis — 1% (low risk to 10% (high risk mortality)Prevention—A)Prevent gallstonesB)Prevent the progression of biliary colic to acute cholecystitis. ?NSAIDs as analgesia for biliary colic, and may alter its natural history by PG alterationsSurgery Low-risk (ASA classes I and II) Cholecystectomy during the same hospital admission.High-risk patients —Percutaneous cholecystostomy with antibiotics prior to cholecystectomy when stableContinued High Risk Patients- Gallstone extraction/ dissolution via percutaneous catheter. Treatment iv Hepatic iminodiacetic acid (HIDA)- no role for oralAddition of morphine increases SOD pressure so better study HIDA scan Radiology Written by Dr Sebastian Zeki

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